A Health Ombud investigation has called for heads to roll after two health workers at the Motherwell NU 11 Clinic were found to be negligent in the case of a teen who was sexually assaulted and sought help before she died.
The evidence also found that protocol for how a patient who has been sexually assaulted was not followed and clinic staff failed to appropriately refer the patient to the next level of care.
Ombud Professor Taole Mokoena released a 63-page report on the matter this week.
The probe looked into allegations that 15-year-old Zenizole Vena was denied provision of care at the Gqeberha, Eastern Cape, clinic, which later led to her death at the Motherwell police station community service centre.
According to the report, in September 2022, Vena was accompanied by an elderly woman to the clinic where she was attended to by two nurses and explained to them what had happened.
“The healthcare workers who attended to Vena at the clinic did not touch nor examine her. They believed that every sexual assault case was a police case that should have been referred to the police. She was instead instructed to go to the Motherwell Police Station Community Service Centre as nurses at the clinic erroneously believed that ‘nurses were not allowed to touch rape victims to avoid tampering with evidence’.
“Despite their belief, the two nurses did not arrange transport, nor call the Motherwell Police Station Community Service Centre and (they) referred without a referral letter. The only option they had was to walk to the police station, which was approximately 2km from the clinic,” the report detailed.
Vena and the elderly woman had no money for a taxi and opted to walk to the police station, however, the teenager collapsed and started having seizures.
A taxi driver offered them a lift to the police station because Vena could no longer walk or talk.
Ombud Mokoena said: “The allegation that the death of Ms Vena was due to the negligence of the nurses at the clinic was substantiated and confirmed. Based on the evidence obtained, it can be concluded that Vena was not attended to in a manner that was consistent with the nature and severity of her health condition at Motherwell NU 11 Clinic. The investigation further revealed additional findings, such as the failure of the Motherwell Police Station Community Service Centre to assist Vena upon her arrival at the charge office. Vena was told to wait; they only attended to her after she waited for 1 hour 30 minutes.
During this time, she experienced seizures and was foaming at the mouth.
She was found dead on the floor of the charge office. No first aid assistance had been offered.
“The toxicology report uncovered a white substance in the stomach that looked like tablets. The suspected cause of death could be in keeping with a high level of trimethoprim, also known as co-trimoxazole, in the stomach contents, the blood, eye fluids and bile.”
Toxicology results indicated that the cause of death was consistent with trimethoprim overdosage.
Police had brought three people in for questioning concerning Vena’s rape and death. Two of them claimed to have seen her take pills.
All three minors were released into their parents’ care, and the matter is yet to be decided on by the deputy director of public prosecutions.
The report further revealed that although the clinic conducted an internal probe, no action was taken against the two nurses.
Among recommendations was that the district manager of the Nelson Mandela Bay District Health institute a disciplinary inquiry against the two health workers who attended to Vena, within one month.
They also recommended the nurses be referred to the South African Nursing Council (SANC) for investigation regarding professional misconduct.
Health Minister Dr Joe Phaahla, who also spoke on behalf of the Eastern Cape Department of Health, said they accept the report into the “serious negligence” that led to the tragic incident.
“Ms Vena received appalling service, which is described as the cause of death and could have been avoided if the nursing staff on duty had acted professionally as required by both the professional ethics conduct and the employer workforce guidelines. These acts constitute neglect of duty and responsibilities in this health facility and deserve nothing but the strongest condemnation.
“The patient was not screened since no vitals signs were recorded; the protocol for how a patient who has been sexually assaulted, in line with the Adult Primary Care Guideline, the APC Guideline, was not followed and the clinic staff failed to appropriately refer the patient to the next level of care. However, it was reported that the staff in question have received training on APC, and it is most disappointing that the APC Guideline was not followed since if the staff did so, all the above shortcomings would not have occurred,” he said.
According to Phaahla, the Eastern Cape Department of Health has already been requested to institute a disciplinary process to ensure appropriate sanctions to the staff and correct shortcomings.
He said measures would also be taken by the Nelson Mandela Bay Health District Office to rectify and improve service delivery in recommended areas.
Eastern Cape police spokesperson Priscilla Naidu said they were not in possession of the report and therefore could not comment on the allegations against Motherwell Police Station or the recommendation.
Naidu said: “The report must formally be sent to the SAPS for review and comment.”
According to the report, on October 16 Mokoena issued a provisional report to all implicated parties but no comments were received from them and, as a result, the report was finalised without their comments.
A recommendation was also made that within 12 months of the report, plans are in place that all police employees engaged with the public are trained in first aid or have easy physical access to first responders 24 hours a day.